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To provide annually updated evidence-based recommendations for the prevention, diagnosis, assessment, and treatment of hypertension in adults for 2013

Target Population

Canadian adult population with or at risk for hypertension, including patients with hypertension associated with ischemic heart disease, heart failure, stroke, left ventricular hypertrophy, nondiabetic kidney disease, renovascular disease, diabetes mellitus, and secondary hypertension due to endocrine causes such as hyperaldosteronism and pheochromocytoma

Note: These recommendations focus on adult care and are predominantly targeted toward primary care providers. For issues related to the diagnosis and evaluation of high blood pressure in children and adolescents, the reader is referred to separate guidelines.

Methodology

Hand-searches of Published Literature (Primary Sources)Hand-searches of Published Literature (Secondary Sources)Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

A systematic literature search was performed by a Cochrane Collaboration librarian in MEDLINE/PubMed, as well as PsycINFO for the Adherence section, using text words and MeSH headings. Search terms included hypertension [MeSH], hypertens*[ti, ab], and blood pressure; these were combined with topic-specific terms to generate search results for each subgroup to review. The search is current to August 2012. Bibliographies of identified articles were also manually searched (details of search strategies and retrieved articles are available upon request). Randomized controlled trials and systematic reviews of randomized trials were reviewed for treatment recommendations and cross-sectional and cohort studies were reviewed for assessing diagnosis and prognosis.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert ConsensusWeighting According to a Rating Scheme (Scheme Not Given)

Rating Scheme for the Strength of the Evidence

See the Rating Scheme for the Strength of the Recommendations" field.

Methods Used to Analyze the Evidence

Review of Published Meta-AnalysesSystematic Review

Description of the Methods Used to Analyze the Evidence

Studies that included relevant outcomes were selected for further review. Cardiovascular morbidity and mortality and total mortality outcomes were prioritized. For health behavior recommendations, blood pressure was considered an acceptable surrogate and, in patients with chronic kidney disease (CKD), progressive renal impairment was considered to be a clinically important outcome. Study characteristics and study quality were assessed using prespecified, standardized algorithms developed by the Canadian Hypertension Education Program (CHEP) for critical appraisal of randomized controlled trials and cohort studies.

Methods Used to Formulate the Recommendations

Expert Consensus (Consensus Development Conference)

Description of Methods Used to Formulate the Recommendations

The Canadian Hypertension Education Program (CHEP) Recommendations Task Force is a multidisciplinary panel comprised of 2 co-chairs and 23 subgroups. Subgroup members, considered content experts in their fields, were responsible for reviewing annual search results and, if indicated, drafting new recommendations or proposing changes to old recommendations. An independent central review committee of methodology experts who had no industry affiliations separately reviewed, graded, and refined proposed recommendations, which were then presented at a 1-day consensus conference in Toronto. Members of the Canadian Task Force on Preventive Health Care, Canadian Diabetes Association Guidelines Committee, Canadian Society of Nephrology, Canadian Stroke Network, and the Canadian Cardiovascular Harmonized National Guideline Endeavour Initiative also collaborated with CHEP subgroup members to ensure harmonization of recommendations between organizations. Existing CHEP recommendations are annually updated and relevant emerging hypertension issues identified by CHEP members and the target population (health care providers) are reviewed.

Recommendations were graded according to the strength of their underlying evidence (for details, see the "Rating Scheme for the Strength of the Recommendations" field), ranging from Grade A (strongest evidence, based on high-quality randomized clinical trials) to Grade D (weakest evidence, based on low power, imprecise studies or expert opinion alone).

The recommendations process is in accord with the Appraisal of Guidelines for Research and Evaluation (AGREE) II guidelines and has been externally reviewed.

Rating Scheme for the Strength of the Recommendations

Grading Scheme for Recommendations

Grade A

Recommendations are based on randomized trials (or systematic reviews of trials) with high levels of internal validity and statistical precision, and for which the study results can be directly applied to patients because of similar clinical characteristics and the clinical relevance of the study outcomes.

Grade B

Recommendations are based on randomized trials, systematic reviews or prespecified subgroup analyses of randomized trials that have lower precision, or there is a need to extrapolate from studies because of differing populations or reporting of validated intermediate/surrogate outcomes rather than clinically important outcomes.

Grade C

Recommendations are based on trials that have lower levels of internal validity and/or precision, or trials reporting unvalidated surrogate outcomes, or results from non-randomized observational studies.

Grade D

Recommendations are based on expert opinion alone.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review

Description of Method of Guideline Validation

After the consensus meeting, proposed recommendations were finalized and submitted to all 62 voting members of the Canadian Hypertension Education Program (CHEP) Evidence-Based Recommendations Task Force for approval. Members with potential conflicts of interest recused themselves from voting on specific recommendations. Recommendations receiving more than 70% approval were passed. This year, both newly proposed recommendations received at least 80% approval.

Recommendations

Definitions for the strength of the recommendations (A-D) are provided at the end of the "Major Recommendations" field.

Diagnosis and Assessment

Accurate Measurement of Blood Pressure (BP)

Health care professionals who have been specifically trained to measure BP accurately should assess BP in all adult patients at all appropriate visits to determine cardiovascular risk and monitor antihypertensive treatment (Grade D).

Criteria for Diagnosis of Hypertension and Recommendations for Follow-up (see Figure 1 in the original guideline document)

At initial presentation, patients demonstrating features of a hypertensive urgency or emergency (see Supplemental Table S3 in the original guideline document) should be diagnosed as hypertensive and require immediate management (Grade D).

At the initial visit for the assessment of hypertension, if SBP is ≥140 and/or DBP is ≥90 mm Hg, more than 2 additional readings should be taken during the same visit using a validated device and according to the recommended procedure for accurate BP determination (see Supplemental Table S2 [see the "Availability of Companion Documents" field]). The first reading should be discarded and the latter 2 readings averaged. A history and physical examination should be performed and, if clinically indicated, diagnostic tests to search for target organ damage (see Supplemental Table S4 [see the "Availability of Companion Documents" field]) and associated cardiovascular risk factors (see Supplemental Table S5 [see the "Availability of Companion Documents" field]) should be arranged within 2 visits. Exogenous factors that can induce or aggravate hypertension should be assessed and removed if possible (See supplemental Table S6 in the original guideline document). Visit 2 should be scheduled within 1 month (Grade D).

At visit 2 for the assessment of hypertension, patients without macrovascular target organ damage, diabetes mellitus, or CKD can be diagnosed as hypertensive if the SBP is ≥180 mm Hg and/or the DBP is ≥110 mm Hg (Grade D). Patients without macrovascular target organ damage, diabetes mellitus, or CKD but with lower BP levels should undergo further evaluation using any of the 3 approaches outlined next:

OBPM: Using manual OBPM, patients can be diagnosed as hypertensive if the SBP is ≥160 mm Hg or the DBP is ≥100 mm Hg averaged across the first 3 visits, or if the SBP averages ≥140 mm Hg or the DBP averages ≥90 mm Hg averaged across 5 visits (Grade D).

Ambulatory BP measurement (ABPM): Using ABPM (see Recommendations in section VIII. ABPM below), patients can be diagnosed as hypertensive if the mean awake SBP is ≥135 mm Hg or the DBP is ≥85 mm Hg or if the mean 24-hour SBP is ≥130 mm Hg or the DBP is ≥ 80 mm Hg (Grade C).

Home BP monitoring (HBPM): Using HBPM (see Recommendations in section VII. HBPM below), patients can be diagnosed as hypertensive if the average SBP is ≥135 mm Hg or the DBP is ≥85 mm Hg (Grade C). If the average home BP is <135/85 mm Hg, it is advisable to either repeat home monitoring to confirm the home BP is <135/85 mm Hg or perform 24-hour ABPM to confirm that the mean 24-hour ABPM is <130/80 mm Hg and the mean awake ABPM is <135/85 mm Hg before diagnosing white coat hypertension (Grade D).

Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined in sections V and VI below) (Grade D).

If at the last diagnostic visit the patient is not diagnosed as hypertensive and has no evidence of macrovascular target organ damage, the patient's BP should be assessed at yearly intervals (Grade D).

Patients taking antihypertensive drugs should be seen monthly or every 2 months, depending on the level of BP, until readings on 2 consecutive visits are below their target (Grade D). Shorter intervals between visits will be needed for symptomatic patients and those with severe hypertension, intolerance to antihypertensive drugs, or target organ damage (Grade D). When the target BP has been reached, patients should be seen at 3- to 6-month intervals (Grade D).

Assessment of Overall Cardiovascular Risk in Hypertensive Patients

Global cardiovascular risk should be assessed. Multifactorial risk assessment models can be used to predict more accurately an individual's global cardiovascular risk (Grade A) and to use antihypertensive therapy more efficiently (Grade D). In the absence of Canadian data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions (Grade C).

Consider informing patients of their global risk to improve the effectiveness of risk-factor modification (Grade B). Consider also using analogies that describe comparative risk such as "cardiovascular age," "vascular age," or "heart age" to inform patients of their risk status (Grade B).

Routine and Optional Laboratory Tests for the Investigation of Patients with Hypertension

Routine laboratory tests that should be performed for the investigation of all patients with hypertension include the following:

All treated hypertensive patients should be monitored according to the current Canadian Diabetes Association guidelines for the new appearance of diabetes (Grade B).

During the maintenance phase of hypertension management, tests (including those for electrolytes, creatinine, and fasting lipids) should be repeated with a frequency reflecting the clinical situation (Grade D).

For patients with suspected hyperaldosteronism (on the basis of the screening test, see Supplemental Table S7, Item iii [see the "Availability of Companion Documents" field]), a diagnosis of primary aldosteronism should be established by demonstrating inappropriate autonomous hypersecretion of aldosterone using at least 1 of the maneuvers listed in Supplemental Table S7, Item iv (see the "Availability of Companion Documents" field). When the diagnosis is established, the abnormality should be localized using any of the tests described in Supplemental Table S7, Item v (see the "Availability of Companion Documents" field).

Pheochromocytoma: Screening and Diagnosis

If pheochromocytoma is strongly suspected, the patient should be referred to a specialized hypertension center, particularly if biochemical screening tests (See supplemental Table S8 in the original guideline document) have already been found to be positive (Grade D).

The following patients should be considered for screening for pheochromocytoma (Grade D):

The use of HBPM on a regular basis should be considered for patients with hypertension, particularly those with:

Diabetes mellitus (Grade D)

CKD (Grade C)

Suspected nonadherence (Grade D)

Demonstrated white coat effect (Grade C)

BP controlled in the office but not at home (masked hypertension) (Grade C)

When white coat hypertension is suggested by HBPM, its presence should be confirmed by repeat HBPM (see Recommendation 8 in this section) or ABPM before treatment decisions are made (Grade D).

Patients should be advised to purchase and use only HBPM devices that are appropriate for the individual and have met standards of the Association for the Advancement of Medical Instrumentation, the most recent requirements of the British Hypertension Society protocol, or the International Protocol for validation of automated BP measuring devices. Patients should be encouraged to use devices with data recording capabilities or automatic data transmission to increase the reliability of reported HBPM (Grade D).

Health care professionals should ensure that patients who measure their BP at home have adequate training and, if necessary, repeat training in measuring their BP. Patients should be observed to determine that they measure BP correctly and should be given adequate information about interpreting these readings (Grade D).

The accuracy of all individual patients' validated devices (including electronic devices) must be regularly checked against a device of known calibration (Grade D).

HBPM for assessing white coat hypertension or sustained hypertension should be based on duplicate measures, morning and evening, for an initial 7-day period. First-day home BP values should not be considered (Grade D).

ABPM

ABPM can be used in the diagnosis of hypertension (Grade C). ABPM should be considered when an office-induced increase in BP is suspected in treated patients with:

Physicians should use only ABPM devices that have been validated independently using established protocols (Grade D).

Therapy adjustment should be considered in patients with a mean 24-hour ambulatory SBP of ≥130 mm Hg or DBP of ≥80 mm Hg or a mean awake SBP of ≥135 mm Hg or DBP of ≥85 mm Hg (Grade D).

The magnitude of changes in nocturnal BP should be taken into account in any decision to prescribe or withhold drug therapy based on ABPM (Grade C) because a decrease in nocturnal BP of <10% is associated with increased risk of cardiovascular events.

Role of Echocardiography

Routine echocardiographic evaluation of all hypertensive patients is not recommended (Grade D).

An echocardiogram for assessment of left ventricular hypertrophy is useful in selected cases to help define the future risk of cardiovascular events (Grade C).

Echocardiographic assessment of left ventricular mass, and of systolic and diastolic left ventricular function is recommended for hypertensive patients suspected to have left ventricular dysfunction or coronary artery disease (Grade D).

Patients with hypertension and evidence of heart failure should have an objective assessment of left ventricular ejection fraction, either by echocardiogram or nuclear imaging (Grade D).

Prevention and Treatment Recommendations

Health Behavior Management

Physical Exercise

For nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise (such as free weight lifting, fixed-weight lifting, or handgrip exercise) does not adversely influence BP (Grade D) (new recommendation). For nonhypertensive individuals (to reduce the possibility of becoming hypertensive) or for hypertensive patients (to reduce their BP), prescribe the accumulation of 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living (Grade D). Higher intensities of exercise are not more effective (Grade D).

Weight Reduction

Height, weight, and waist circumference should be measured and body mass index calculated for all adults (Grade D).

Maintenance of a healthy body weight (body mass index 18.5-24.9, and waist circumference <102 cm for men and <88 cm for women) is recommended for nonhypertensive individuals to prevent hypertension (Grade C) and for hypertensive patients to reduce BP (Grade B). All overweight hypertensive individuals should be advised to lose weight (Grade B).

To reduce BP, alcohol consumption should be in accordance with Canadian low-risk drinking guidelines in normotensive and hypertensive individuals. Healthy adults should limit alcohol consumption to ≤2 drinks per day, and consumption should not exceed 14 standard drinks per week for men and 9 standard drinks per week for women (Grade B). (Note: 1 standard drink is considered to be equivalent of 13.6 g or 17.2 mL of ethanol or approximately 44 mL [1.5 oz] of 80 proof [40%] spirits, 355 mL [12 oz] of 5% beer, or 148 mL [5 oz] of 12% wine).

For prevention and treatment of hypertension, a dietary sodium intake of 1500 mg (65 mmol) per day is recommended for adults aged ≤50 years; 1300 mg (57 mmol) per day for age 51-70 years; and 1200 mg (52 mmol) per day for age >70 years (Grade B).

Potassium, Calcium, and Magnesium Intake

Supplementation of potassium, calcium, and magnesium is not recommended for the prevention or treatment of hypertension (Grade B).

Stress Management

In hypertensive patients in whom stress might be contributing to BP elevation, stress management should be considered as an intervention (Grade D). Individualized cognitive-behavioral interventions are more likely to be effective when relaxation techniques are used (Grade B).

Indications for Drug Therapy for Adults with Hypertension without Compelling Indications for Specific Agents

Antihypertensive therapy should be prescribed for average DBP measurements of ≥100 mm Hg (Grade A) or average SBP measurements of ≥160 mm Hg (Grade A) in patients without macrovascular target organ damage or other cardiovascular risk factors.

Antihypertensive therapy should be strongly considered if DBP readings average ≥90 mm Hg in the presence of macrovascular target organ damage or other independent cardiovascular risk factors (Grade A).

Antihypertensive therapy should be strongly considered if SBP readings average ≥140 mm Hg in the presence of macrovascular target organ damage (Grade C for 140-160 mm Hg; Grade A for >160 mm Hg).

Antihypertensive therapy should be considered in all patients meeting indications 1-3 in this section, regardless of age (Grade B). Caution should be exercised in elderly patients who are frail.

Choice of Therapy for Adults with Hypertension without Compelling Indications for Specific Agents

Initial therapy should be monotherapy with a thiazide diuretic (Grade A), a β-blocker (in patients younger than 60 years; Grade B), an ACE inhibitor (in nonblack patients; Grade B), a long-acting calcium channel blocker (CCB) (Grade B); or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic agents alone (Grade C).

Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first-line choices. Useful choices include a thiazide diuretic or CCB with either: ACE inhibitor, ARB, or β-blocker (Grade B for the combination of thiazide diuretic and a dihydropyridine CCB; Grade C for the combination of dihydropyridine CCB and ACE inhibitor; and Grade D for all other combinations). Caution should be exercised in combining a nondihydropyridine CCB and a β-blocker (Grade D). The combination of an ACE inhibitor and an ARB is not recommended (Grade A).

Combination therapy using 2 first-line agents might also be considered as initial treatment of hypertension (Grade C) if SBP is 20 mm Hg above target or if DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in BP from initial combination therapy is more likely to occur or in whom it would be poorly tolerated (e.g., elderly patients).

If BP is still not controlled with a combination of 2 or more first-line agents, or there are adverse effects, other antihypertensive drugs may be added (Grade D).

Possible reasons for poor response to therapy (see Supplemental Table S10 [see the "Availability of Companion Documents" field]) should be considered (Grade D).

α-Blockers are not recommended as first-line agents for uncomplicated hypertension (Grade A); β-blockers are not recommended as first-line therapy for uncomplicated hypertension in patients 60 years of age or older (Grade A); and ACE inhibitors are not recommended as first-line therapy for uncomplicated hypertension in black patients (Grade A). However, these agents may be used in patients with certain comorbid conditions or in combination therapy.

Recommendations for Individuals with Isolated Systolic Hypertension

In the very elderly (age 80 years and older), the target for SBP should be <150 mm Hg (Grade C) (new recommendation).

Initial therapy should be monotherapy with a thiazide diuretic (Grade A), a long-acting dihydropyridine CCB (Grade A), or an ARB (Grade B). If there are adverse effects, another drug from this group should be substituted. Hypokalemia should be avoided in patients treated with thiazide diuretic monotherapy (Grade C).

Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy (Grade B). Add-on drugs should be chosen from first-line options (Grade D).

If BP is still not controlled with a combination of 2 or more first-line agents, or there are adverse effects, other classes of drugs (such as α-blockers, ACE inhibitors, centrally acting agents, or non-dihydropyridine CCBs) may be added or substituted (Grade D).

Possible reasons for poor response to therapy (see Supplemental Table S10 [see the "Availability of Companion Documents" field]) should be considered (Grade D).

α-Blockers are not recommended as first-line agents for uncomplicated isolated systolic hypertension (Grade A); and β-blockers are not recommended as first-line therapy for isolated systolic hypertension in patients aged ≥60 years (Grade A). However, both agents may be used in patients with certain comorbid conditions or in combination therapy.

Statin therapy is recommended in hypertensive patients with 3 or more cardiovascular risk factors as defined in Supplemental Table S11 (see the "Availability of Companion Documents" field) in the original guideline document (Grade A in patients >40 years), or with established atherosclerotic disease (Grade A regardless of age).

Strong consideration should be given to the addition of low-dose acetylsalicylic acid therapy in hypertensive patients (Grade A in patients >50 years). Caution should be exercised if BP is not controlled (Grade C).

Goal of Therapy for Adults with Hypertension without Compelling Indications for Specific Agents

An ACE inhibitor or ARB is recommended for most patients with hypertension and coronary artery disease (Grade A).

For patients with stable angina, β-blockers are preferred as initial therapy (Grade B). CCBs may also be used (Grade B).

Short-acting nifedipine should not be used (Grade D).

For patients with coronary artery disease, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).

In high-risk patients, when combination therapy is being used, choices should be individualized. The combination of an ACE inhibitor and a dihydropyridine CCB is preferable to an ACE inhibitor and a diuretic in selected patients (GradeA).

Recommendations for Patients with Hypertension Who Have Had a Recent Myocardial Infarction

Initial therapy should include both a β-blocker and an ACE inhibitor (Grade A).

An ARB can be used if the patient is intolerant of an ACE inhibitor (Grade A in patients with left ventricular systolic dysfunction).

CCBs may be used in patients after myocardial infarction when β-blockers are contraindicated or not effective. Nondihydropyridine CCBs should not be used when there is heart failure, as evidenced by pulmonary congestion on examination or radiography (Grade D).

Treatment of Hypertension in Association with Heart Failure

In patients with systolic dysfunction (ejection fraction <40%), ACE inhibitors (GradeA) and β-blockers (Grade A) are recommended for initial therapy. Aldosterone antagonists (mineralocorticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide level, or New York Heart Association class II to IV symptoms (Grade A). Careful monitoring for hyperkalemia is recommended when adding an aldosterone antagonist to ACE inhibitor or ARB therapy. Other diuretics are recommended as additional therapy if needed (Grade B for thiazide diuretics for BP control, Grade D for loop diuretics for volume control). Beyond considerations of BP control, doses of ACE inhibitors or ARBs should be titrated to those found to be effective in trials unless adverse effects become manifest (Grade B).

An ARB is recommended if ACE inhibitors are not tolerated (Grade A).

A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contraindicated or not tolerated (Grade B).

For hypertensive patients whose BP is not controlled, an ARB may be added to an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if combining an ACE inhibitor and an ARB because of potential adverse effects such as hypotension, hyperkalemia, and worsening renal function (Grade C). Additional therapies might also include dihydropyridine CCBs (Grade C).

Treatment of Hypertension in Association with Stroke

BP Management in Acute Stroke (Onset to 72 Hours)

For patients with ischemic stroke not eligible for thrombolytic therapy, treatment of hypertension in the setting of acute ischemic stroke or transient ischemic attack should not be routinely undertaken (Grade D). Extreme BP elevation (e.g., SBP >220 mm Hg or DBP >120 mm Hg) may be treated to reduce the BP by approximately 15% (Grade D), and not more than 25%, over the first 24 hours with gradual reduction thereafter (Grade D). Avoid excessive lowering of BP because this might exacerbate existing ischemia or might induce ischemia, particularly in the setting of intracranial arterial occlusion or extracranial carotid or vertebral artery occlusion (Grade D). Pharmacological agents and routes of administration should be chosen to avoid precipitous falls in BP (Grade D).

For patients with ischemic stroke eligible for thrombolytic therapy, very high BP (>185/110 mm Hg) should be treated concurrently in patients receiving thrombolytic therapy for acute ischemic stroke to reduce the risk of secondary intracranial hemorrhage (Grade B).

BP Management after Acute Stroke

Strong consideration should be given to the initiation of antihypertensive therapy after the acute phase of a stroke or transient ischemic attack (Grade A).

After the acute phase of a stroke, BP-lowering treatment is recommended to a target of BP consistently <140/90 mm Hg (Grade C).

For patients with stroke, the combination of an ACE inhibitor and ARB is not recommended (Grade B).

Treatment of Hypertension in Association with Left Ventricular Hypertrophy

Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events (Grade C).

The choice of initial therapy can be influenced by the presence of left ventricular hypertrophy (Grade D). Initial therapy can be drug treatment using ACE inhibitors, ARBs, long-acting CCBs, or thiazide diuretics. Direct arterial vasodilators such as hydralazine or minoxidil should not be used.

For patients with hypertension and proteinuric CKD (urinary protein >500 mg per 24 hours or albumin-to-creatinine ratio >30 mg/mmol), initial therapy should be an ACE inhibitor (Grade A) or an ARB if there is intolerance to ACE inhibitors (Grade B).

In most cases, combination therapy with other antihypertensive agents might be needed to reach target BP levels (Grade D).

The combination of an ACE inhibitor and ARB is not recommended for patients with nonproteinuric CKD (Grade B).

Treatment of Hypertension in Association with Renovascular Disease

Renovascular hypertension should be treated in the same manner as hypertension without compelling indications, except for caution in the use of ACE inhibitors or ARBs because of the risk of acute renal failure in bilateral disease or unilateral disease with a solitary kidney (Grade D).

Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with uncontrolled hypertension despite therapy with ≥3 drugs, deteriorating kidney function, bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema (Grade D).

Treatment of Hypertension in Association with Diabetes Mellitus

Persons with diabetes mellitus should be treated to attain SBPs of <130 mm Hg (Grade C) and DBPs of <80 mm Hg (Grade A). (These target BP levels are the same as the BP treatment thresholds.) Combination therapy using 2 first-line agents might also be considered as initial treatment of hypertension (Grade B) if SBP is 20 mm Hg above target or if DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in BP is more likely or poorly tolerated (e.g., elderly patients and patients with autonomic neuropathy).

For persons with cardiovascular or kidney disease, including microalbuminuria or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy (Grade A).

If target BP levels are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to hydrochlorothiazide (Grade A).

Adherence Strategies for Patients

Adherence to an antihypertensive prescription can be improved by a multipronged approach (see Supplemental Table S12 [see the "Availability of Companion Documents" field]).

Treatment of Secondary Hypertension Due to Endocrine Causes

Treatment of hyperaldosteronism and pheochromocytoma are outlined in Supplemental Tables S13 and S14 (see the "Availability of Companion Documents" field).

Definitions:

Grading Scheme for Recommendations

Grade A

Recommendations are based on randomized trials (or systematic reviews of trials) with high levels of internal validity and statistical precision, and for which the study results can be directly applied to patients because of similar clinical characteristics and the clinical relevance of the study outcomes.

Grade B

Recommendations are based on randomized trials, systematic reviews or prespecified subgroup analyses of randomized trials that have lower precision, or there is a need to extrapolate from studies because of differing populations or reporting of validated intermediate/surrogate outcomes rather than clinically important outcomes.

Grade C

Recommendations are based on trials that have lower levels of internal validity and/or precision, or trials reporting unvalidated surrogate outcomes, or results from non-randomized observational studies.

Grade D

Recommendations are based on expert opinion alone.

Clinical Algorithm(s)

An algorithm for the expedited assessment and diagnosis of patients with hypertension with a focus on validated technologies for blood pressure assessment is provided in the original guideline document.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved hypertension prevention, detection, and management in the Canadian population

Potential Harms

Adverse effects of antihypertensive medications

Careful monitoring should be used if combining an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin-receptor blocker (ARB) because of potential adverse effects such as hypotension, hyperkalemia, and worsening renal function.

Refer to Table 1 in the original guideline document for additional cautions concerning antihypertensive therapy.

Qualifying Statements

Qualifying Statements

Although individual antihypertensive agents might be mentioned when discussing evidence, the reader should presume the existence of a class effect unless otherwise stated. In addition, these recommendations are intended as a guide for health care practitioners and should not replace sound clinical judgement. They also do not take economic considerations into account. Health care providers are also advised to consider patient preferences when applying these recommendations to their patients.

Implementation of the Guideline

Description of Implementation Strategy

The implementation task force conducts an extensive knowledge translation effort to enhance uptake and applicability of these recommendations. These efforts include knowledge exchange forums, targeted educational materials for primary care providers and patients, and freely available slide kits and summary documents of all recommendations on the Canadian Hypertension Society Web site. Documents are available in French and English, and some documents are translated into other languages. The Canadian Hypertension Education Program (CHEP) outcomes task force conducts hypertension surveillance studies and reviews existing Canadian health surveys to identify gaps between current and best practices. The implementation task force also regularly receives feedback from end users to improve guideline processes and content. Although the number of primary care providers that directly receive CHEP materials on a regular basis has dramatically increased, CHEP is continuing to address the challenge of identifying and reaching all active primary care providers across Canada, through use of the hypertension.ca website, "Train the Trainer" teaching sessions, and wide dissemination of educational materials.

The Canadian Hypertension Education Program (CHEP) is operated and funded by Hypertension Canada. The members of the CHEP Committee are unpaid volunteers who contribute their time and expertise to the annual development and dissemination of the CHEP Recommendations. To maintain professional credibility of the content, the process for the development of the recommendations is fully independent and free from external influence. External partners assist with the dissemination of the approved recommendations.

A variety of resources, including key messages, a one-page summary, slide sets, and resources for managing and measuring blood pressure, sodium, and hypertension and diabetes are available in English and French from the Canadian Hypertension Society Web site.

Patient Resources

A variety of patient resources are available in English and French from the Canadian Hypertension Society Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on September 10, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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